So did he really cut that hand seen below at work?
The answer, of course, is no. On further questioning, he admits to being in a fight about 6 hours prior. He did not seek attention earlier, as he was concerned about legal ramifications.
This is a classic fight bite. A fight bite is a cut sustained during an altercation from the closed fist striking a sharp object, most often a tooth. It is usually located over or between the MCP from the 2nd-5th digits on the dominant hand. These patients usually do not come in right away as they are often concerned about the ramifications, so late presentation with a serious infection is often noted.
How do you manage these patients?
A. Get the history. Establish which is the dominant hand.
B. Careful wound examination: Make sure to evaluate for neurovascular injury, tendon injury, or joint involvement. Make especially to look for foreign bodies (glass, teeth, etc). Joint involvement or signs of serious infection mandate hospitalization.
C. Xray: Look for boxer’s fractures and foreign bodies.
D. Copious irrigation, and leave the wound open. 10-15% of human bites on the hand become infected (1). This is a big deal. The hand is a small, closed space, and infections can be devastating. Extension of the hand in the hours between the incident and presentation can actually lead to proximal infectious spread along extensor tendons. Closing up the wound can lead to preventing drainage. Large, gaping wounds may be loosely approximated, but again with caution.
E. Hand consultation and broad spectrum antibiotics. If there are signs of serious infection or the potential for this (this gentleman had streaking proximally to the wrist from the wound), consult for admission. People who present early and who can be irrigated and have good follow up may be discharged with a loose dressing, broad spectrum antibiotics, and close follow p, although this should be done in consultation with a hand surgeon and again only if close follow up can be done. Remember, the boards/inservice answer is hand surgeon consultation (2).
Regarding your bacteria and antibiotic choices, the boards buzzword for human bites is Eikinella corrodens. The human mouth is disgusting, full of multiple anaerobes and is to be considered a cesspool. Eikinella is covered by penicillins, later generation cephalosporins, and tetracyclines. Penicillins or clindamycin in the penicillin allergic patient covers against normal oral flora. Again, my go to for parenteral antibiotics is Unasyn. Staph infections are uncommon and usually secondary.
2. Emergency Medicine: A focused Review of the Core Curriculum. AAEM. pgs 401-402